New Patient Form

For your convenience, feel free to complete this New Patient Form prior to seeing your doctor to save yourself time and ensure that you are able to get the most out of your appointment. New patients are requested to complete this form to provide Clifton Hill Dermatology with all relevant information.

Please select the doctor you will be seeing and complete the form below.

Appointment with Dr Karen Wolfowitz / Appointment with Dr Barbara Breadon

Emergency Contact Details

Medical History

Surgical Procedures

If you are having a skin check, your Dermatologist may suggest a biopsy be carried out. A biopsy is a surgical procedure (e.g. a curette, a shave, or an excision) used to obtain a sample of tissue for diagnostic purposes. The entire lesion may/may not be removed in this procedure. Further medical or surgical treatment may be needed once a diagnosis has been made. You will be notified if further treatment is required. Local anaesthetic will be used with this procedure. Please inform staff if you have had a previous adverse reaction to local anaesthetic (Lignocaine +/adrenalin) or heart problems. Diat A biopsy is a surgical procedure used to obtain a sample of tissue for diagnostic purposes. The entire lesion may/may not be removed in this procedure. Further medical or surgical treatment may be needed when the diagnosis is made. Surgical procedures will incur additional costs. A quotation can
be requested.

There is a risk that a surgical procedure may be complicated by wound infection, bleeding, bruising, scarring, including keloid and hypertrophic scarring, stretching of the wound, hypopigmentation or hyperpigmentation. Please feel free to discuss these complications with your doctor during the consultation.

Local anaesthetic will be used with this procedure. Please inform staff if you have had a previous adverse reaction to local anaesthetic (Lignocaine/Adrenaline).
I agree to the terms and conditions above:

Imaging

Imaging of lesions using a Molemax machine may be recommended during your consultation in order to monitor these lesions in future. The Molemax imaging charge is $125.

These images may be used anonymously for educational purposes.

I agree to the terms and conditions above:

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

Appointment with Dr Shyamalar Gunatheesan / Appointment with Dr Alfonso Perez

Emergency Contact Details

Medical History

Surgical Procedures

If you are having a skin check, your Dermatologist may suggest a biopsy be carried out. A biopsy is a surgical procedure (e.g. a curette, a shave, or an excision) used to obtain a sample of tissue for diagnostic purposes. The entire lesion may/may not be removed in this procedure. Further medical or surgical treatment may be needed once a diagnosis has been made. You will be notified if further treatment is required.

Local anaesthetic will be used with this procedure. Please inform staff if you have had a previous adverse reaction to local anaesthetic (Lignocaine +/adrenalin) or heart problems. Diathermy may be used. Please inform the staff if you have a pacemaker/artificial heart valves.

Possible risks associated with biopsies include; pain, bleeding, infection, scarring (hypopigmented or hyperpigmented), recurrence of lesion and needing repeat.

Surgical procedures will incur additional costs to the basic consultation fee. A quotation can be given upon request.

I agree to the terms and conditions above:

Imaging

Imaging of lesions using a Molemax machine may be recommended during your consultation in order to monitor these lesions in future. The Molemax imaging charge is $125.

These images may be used anonymously for educational purposes.

I agree to the terms and conditions above:

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.